Share

Topics: Veterans Affairs

Delayed tests, inadequate care linked to 23 cancer patient deaths at Veterans Affairs hospitals

By |
Watchdog,Mark Flatten,Veterans Affairs,Health Care,Accountability,Veterans,Cancer

Delays in cancer screenings contributed to as many as 23 patient deaths at Department of Veterans Affairs hospitals nationwide, according to an agency document.

Another 53 patients suffered some type of harm as a result of improper care related to gastrointestinal cancer testing or treatment, according to the April 2014 fact sheet produced by the veterans' agency.

The document does not say the deaths were directly caused by delays in providing medical tests. Rather, it says 76 patients with gastrointestinal cancer or their survivors were notified of adverse issues related to their care, and that 23 of them died.

Some of the deaths were already known.

An inspector general's report issued in September linked six patient deaths at the Dorn VA Medical Center in Columbia, S.C., to delayed colonoscopies or other screenings that could have detected early stages of colorectal cancers.

Other internal Veterans Affairs documents reported 19 patient deaths nationwide related to delayed endoscopic procedures, but the location of 10 of those deaths had not been previously disclosed.

The new document raises that total to 23. It does not disclose when the patients died. What it does show is the number of “institutional disclosures” related to delayed or improper care of patients with gastrointestinal cancers.

As noted in the IG’s report, early detection can reduce mortality of colorectal cancers by 70-80 percent. Colorectal cancer is the second leading cause of cancer deaths in the United States, according to the report.

The 23 deaths are only for patients with gastrointestinal cancers. Other patient deaths from Legionnaires' disease and inadequate mental health treatment have been disclosed at other veterans facilities, but are not discussed in the new report.

The April fact sheet from VA, obtained by the Washington Examiner from sources outside the agency, lists the six deaths at Columbia, as well as 20 other patients at the facility with gastrointestinal cancer in which institutional disclosures were made.

Other hospitals with multiple patient deaths are in Georgia, Virginia and Florida. Two veterans' medical centers in Florida reported two deaths each and a third, in Miami, had a single patient death from gastrointestinal cancer.

Florida Gov. Rick Scott asked state health officials to inspect Florida VA hospitals earlier this month, but they were turned away from the West Palm Beach facility where two cancer deaths occurred.

“These heartbreaking findings are just the first step VA must take in rebuilding the trust of the veterans and family members affected by these tragic delays in care,” said Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans Affairs.

“In addition to swiftly putting in place reforms to ensure this never happens again, it is incumbent upon VA to reveal precisely when these deaths and injuries occurred and whether any VA employees who may have allowed veterans to fall through the cracks have been held accountable. Unfortunately, we haven’t seen any evidence so far indicating that preventable deaths at VA facilities result in serious discipline for the employees responsible.”

Miller said top administrators at veterans' hospitals where preventable patient deaths have occurred are more likely to get merit bonuses or positive performance reviews than they are to be punished.

Miller is sponsoring a bill that would make it easier for top administrators at the veterans' agency to be fired or disciplined for poor performance.

“Until department leaders take steps to ensure VA employees and executives are adequately punished rather than rewarded for mistakes, it is simply illogical to think the many problems plaguing VA will subside,” Miller said.

Miller’s committee will hold a hearing on preventable patient deaths Wednesday.

The VA review of patient deaths was triggered by disclosures of preventable patient deaths Columbia and in Augusta, Ga., according to a statement issued by the agency.

More than 250 million consult orders, which include orders for medical tests, going back to 1999 were reviewed internally.

“Any adverse incident for a Veteran within our care is one too many,” the VA statement says. “When an incident occurs in our system we aggressively identify, correct and work to prevent additional risks. We conduct a thorough review to understand what happened, prevent similar incidents in the future, and share lessons learned across the system."

The Examiner reported in February that VA purged thousands of orders for diagnostic medical tests in an effort to make it appear the agency's decade-long backlog of consult orders was being eliminated.

View article comments Leave a comment